Diagnosis: Stroke.

Treatment: Subacute inpatient stay.

The insurer denied coverage for continued subacute inpatient stay.

The denial is upheld.

This male patient has a history of multiple medical problems including coronary artery disease status myocardial infarction, stroke and alcohol abuse. The patient was admitted to a skilled nursing facility for subacute rehabilitation of his stroke. The patient tested positive for Covid-19. Under review is the medical necessity of continued subacute inpatient stay.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the patient was initially an appropriate candidate for subacute rehabilitation at the skilled nursing facility. The nursing facility had planned for the patient to be discharged home. However, the patient tested positive for Covid-19 and was asymptomatic. The patient was at a high functional level and there were no acute medical or complicated skilled nursing needs to support continued subacute level of care at the skilled nursing facility. In addition, quarantine at the skilled nursing facility (SNF) was not medically necessary or supported for the addition length of stay.

Considerations included the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, continued subacute inpatient stay was no longer medically necessary.

The health plan acted reasonably with medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for continued subacute inpatient rehab stay is not substantiated. The insurer's denial should be upheld.